The Latest in Billing & Reimbursement from Ronda Buhrmester: April 2024

Published in Member Communities on April 03, 2024

By Ronda Buhrmester, Sr. Director of Payer Relations and Reimbursement, VGM & Associates

Read below for several billing & reimbursement-specific updates regarding staying engaged with your PTAN, Medicare allowables, and a reminder on a main issue with oxygen equipment audits.

Stay Engaged with Your PTAN

The National Provider Enrollment (NPE) contractors that govern your PTAN (billing number) have been stricter than ever because of CMS’ oversight. Because the PTAN is vital to cash flow, this is the time to ensure that all 30 supplier standards are being maintained to avoid revocation or deactivation. It is ultimately the supplier’s responsibility to maintain compliance with the standards, ensuring that the enrollment contractor has been kept updated with any renewals for licenses, surety bonds, liability insurance, etc., in addition to any changes related to these standards (store hours, address, contact information, etc.). There should be a staff member overseeing the supplier standards compliance. Most companies have a compliance officer or someone at a senior management level or higher that oversees this area. Whatever you do to remember a birthday or anniversary, do the same here for those documents that require renewal.

With that being said, we know site inspectors show up unannounced for things like revalidations and address changes. The site inspectors are contracted by CMS. This means the site inspector does not work for the enrollment contractor; instead, they work with the enrollment contractor. We have heard in the industry that some issues have arisen with site inspectors. If your business has experienced this issue, you can either make me aware (via email) because I am on a council that meets with the NPE contractors quarterly, and/or you can use this link that tracks site inspection issues.

Due to this being another contractor with CMS, we need to make them aware of issues with proof and examples of occurrences. We do not share company-specific names with CMS, only the issues with the site inspectors onsite.

CMS has been making several significant changes to the enrollment area. Once we know of all the details, we will be hosting a webinar.

Are the Allowables Too Low?

I am sure we all responded “yes” to this question. Medicare (CMS) allowables also affect many other payers since they generally base their fee schedules off a Medicare allowable.

The assignment rate for claims submitted to CMS continue to remain at 99%, even as they continue to decrease the rates. I recognize that number does not include a lot of information and can be skewed. However, this is the data that CMS monitors for trends and a basis for decisions.

There is the option of making the claim as non-assigned for those that are enrolled as non-participating. With non-assigned claims, suppliers set the usual and customary charge (no limiting fee), and the patient pays that upfront. The claim is submitted as non-assigned. If there is any reimbursement, the patient gets 80% of the allowed amount plus the 20% that crosses over to their secondary insurance (if they have a secondary). Just like assigned claims, the supplier is responsible for making sure coverage criteria is met for non-assigned claims too.

For capped rental claims, there is a brilliant idea that should be considered. Non-assigned is not required for all 13 months. The supplier can offer month one as non-assigned (front loading the claim), then change the status to assigned for the remainder of the capped rental period. This solution can be done for two months non-assigned of the 13 months, whatever is the best solution for the supplier and patient that will get to the total purchase price by the end of the capped rental period.

Having the ability to charge the usual and customary amount allows suppliers to capture all those pricey overhead expenses. It is ultimately the patient’s decision (not ours) on how to handle the needs for treating their health condition. Let’s not take those rights away from them.

I just presented in a session on this topic at Medtrade in Dallas. If you want to hear more about it, contact me at ronda.buhrmester@vgm.com.

Reminder on a Main Issue with Oxygen Equipment Audits

If your company provides oxygen equipment, you may see an issue with oxygen audits, especially at the DME MAC-targeted probe and educate (TPE) level. Now that both DME MACs are performing TPE audits for oxygen claims, it’s critical to ensure the following requirement is being met.

One of the requirements to get coverage of oxygen equipment is located within the policy article. The requirement states the following:

Evidence of qualifying test results at the time of need; and,
Evidence of an evaluation of the qualifying test results by a treating practitioner.

What does this requirement mean? The expectation is to ensure the treating practitioner has actually reviewed the oxygen-qualifying test results.

To show evidence of this being done, the treating practitioner can do one of the following three:

Mention within the existing chart note language about the test results, or
Add a new chart note discussing the test results (does not require a new visit), or
Co-sign the actual test results.

There have been many issues when the documentation is reviewed within the TPE audits. Educate all your staff involved in oxygen equipment referrals, intake, sales, clinicians, compliance, documentation review, billing, and most importantly the referrals for oxygen equipment including hospitals.

For any questions, please reach out to me, Ronda Buhrmester, via email at ronda.buhrmester@vgm.com or by calling 217-493-5440.

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